This Web-assisted audio teleconference series consisted of three events broadcast on July 25, 26, and August 1, 2001, via the World Wide Web and telephone. The program was designed to help State and local policymakers make policy decisions and allocate resources related to health care informatics. The User Liaison Program (ULP) of the Agency for Healthcare Research and Quality (AHRQ) developed and sponsored the program.
AHRQ Web conference
July 26, 2001
Cindy DiBiasi: Good afternoon. Welcome to "The Next Revolution: The Role of Informatics in Improving Healthcare." This is a series of three Web-assisted teleconferences for State and local health policymakers sponsored by the User Liaison Program under AHRQ (or "Arc"), the Federal Agency for Healthcare Research and Quality. My name is Cindy DiBiasi and I will be your moderator for today's session.
This is the second event of this User Liaison Program Web-assisted teleconference series on the role of informatics in improving healthcare. The healthcare field has potential to benefit greatly from innovative applications of informatics. Everything from online access to health information, integrated electronic medical records, and computer-based information systems to provide practitioners with real-time assistance in their decision-making can offer the potential to significantly improve the quality of care and patient safety. But it is important to separate the fact from the hype and better understand how information technology can be used to improve the delivery of healthcare.
Today's event will address "Using Informatics to Improve Program Performance: Examples of Innovative State Applications." This Web-assisted teleconference will highlight examples of how information technology is being used in an innovative manner within State-sponsored healthcare programs to improve access and enhance the quality and appropriateness and reduce the cost of healthcare provided to program beneficiaries.
Yesterday during the first Web-assisted teleconference in this series, "Potential Impact of Clinical Informatics on Healthcare Costs, Quality, and Safety," we examined the potential and explored what is currently known from health services research concerning the impact of specific clinical informatics interventions on the cost, quality, and safety of healthcare services. We also discussed the implications of developments in the area of health informatics for State and local government.
On Wednesday, August 1, we will address "Getting Information into the Hands of Decision-Makers: Innovative Applications and Issues." This Web-assisted teleconference will examine two related and innovative approaches using informatics to make data, in this case, hospital discharge data, more readily available to policymakers and researchers to support insightful, rapid turnaround, comparative analysis both within and across States. The results of a recent study of the accessibility and quality of health information available to consumers on the Internet and their implications for public policymakers will also be examined.
Today we are going to take a closer look at "Using Informatics to Improve Program Performance: Examples of Innovative State Applications." In the studio with me, I have an expert who will be participating in our discussion. Molly Baldwin is the Manager of Long-term Care at the Maine Bureau of Elder and Adult Services. From Cheyenne, Wyoming, I also have with us Terry Williams, who is the Health Passport Field Demonstration Manager with the Western Governor's Association's Health Passport Pilot Project and the Electronic Benefit Transfer Manager for the Wyoming Department of Health and Family Services. From Sacramento, California is Sandy Shewry, who is the Director of the California Managed Risk Medical Insurance Board, the agency responsible for the administration of that State's Child Health Insurance Program. Welcome everyone.
Before we begin our discussion, I have a few housekeeping items to take care of. If at any point during this event you have Web-related technical difficulties, please use the "Tell" function to contact Tech Support. And if at any point in time you experience difficulty with the audio stream or if you experience an uncomfortable lag time between the streamed audio and slide presentation, please feel free to access the audio by your telephone. That number is 1-888-868-9080. Give the password "AHRQ Web conference." Later in the call, our panel of experts will be taking your questions. There are four ways you can communicate your questions to us. If you are going to use the phone, please listen later for my instructions. You may fax us your questions at (301) 594-0380; you may E-mail us your questions at info@ahrq.gov. You may also directly type your question in a messaging field and hit "enter", but note that your sent message will not appear in the chat box. If you prefer not to use your name when you communicate with us, that's fine, but we'd like to know what State you are from and the name of your department or organization, so please indicate that regardless of the way in which you transmit your question.
We will have audio tapes of this Web-assisted teleconference series available for purchase after all three events are completed and I will give you further details about this at the end of today's show.
And finally, an archive of this Web-assisted teleconference will also be available on the AHRQ ULP Web site and the URL is http://www.ahrq.gov/news/ulpix.htm. Now I think we are ready to turn to the important matter of "Using Informatics to Improve Program Performance: Examples of Innovative State Applications." Molly, I'd like to start with you.
Maine's Bureau of Elder and Adult Services uses portable PCs in conducting in-home assessments of frail elderly persons at risk of nursing home placement and this has helped this State more effectively offer home and community-based services to these individuals as an alternative to costly institutional care. Molly, what was the problem you were trying to address?
Molly Baldwin: Well, if you have ever gone into a room filled with elderly and disabled adults and asked the question, "Who wants to spend their final days in a nursing home?" you are sure not to see any hands go up in the crowd. We knew that consumers definitely wanted choices and options other than nursing home care, but it took the actual coming together of many factors in the early 90's. The biggest factor was the budgetary crisis that we faced in Maine. That caused the legislature and policymakers as well as consumers and advocates to sort of join forces and take this as an opportunity to really re-direct how we spend our resources and allocations for long-term care. We definitely knew we had to find a way to save some money in the process to commit to the budget's deficit at the same time. By having everybody working in unity, we stood a much better chance of coming up with a plan that really would turn and re-allocate those resources to home and community-based services.
At the time that we were in the midst of this crisis, both medical and financial eligibility took up to 90 days or longer. Our governor quickly came on board and initiated long-term care reform and was convinced by everyone, legislators, policymakers, and consumers and advocates, that the only way you could improve people's choices was to improve their access to information about how to get long-term care. Typically, an older person would end up in the hospital, need a quick transition to some other level of care and it was fast and easy to move them into a nursing home. People tend not to think about long-term care and making plans for long-term care until they are in that crisis situation. By creating the opportunity to offer assessments and education and information to consumers, we really believed that consumers would make the choice that they told us they wanted all along: Let us stay in our own home and our own environment.
One of the things the legislature and the governor implemented was a Universal Pre-admission Screening Process. There is actually a State law in the State of Maine that mandates that every consumer wanting to access nursing home care, regardless of the funding source, must have a free pre-admission screening assessment. Part of that assessment has to explain to them and attempt to educate them about their long-term care options. The assessor actually has to give a recommended community-based plan.
One of the other issues that came about is that we found that with having multiple entry points for long-term care across the State meant that if you lived in one part of the State, the outcome of the assessment may be one thing and if you lived in another part of the State, it may be another thing. By creating a single entry point, it meant consumers had a much easier time accessing the assessment and it also meant that all the parties involved in actually financing and determining what level of care you needed had to work together and unite and really collaborate and determine how to best serve the consumer.
Cindy DiBiasi: What was the informatic solution that you developed?
Molly Baldwin: We knew we wanted to develop a system that quickly gave medical and financial eligibility right there at the time the consumer was being assessed. We didn't want any delays. We wanted them to know at the time of the assessment these are your options and this is how we will get you to those options.
After doing paper assessments and having multiple assessments cross fax lines, being lost in the mail, sitting on people's desks waiting to be reviewed, we knew we wanted to develop some kind of technical application that would give us a system that worked quickly, was easy to use, could be expandable, and would help the assessor actually calculate the eligibility. In Maine we have about 14 different long-term care programs and each program has different eligibility and different services available. We wanted it to be a system that could also provide to the assessor, at the time of the assessment, on-the-spot information about their medical and financial information from Legacy Systems that we had in the State. We accomplished that by having daily feeds between those systems.
Cindy DiBiasi: Exactly how are the PCs being used?
Molly Baldwin: Nurse assessors function from their homes, and in our central entry point, the central office, we have desktops that are networked. Nurse assessors dial in each morning. They select assessments that they are willing to accept as being available to schedule and complete. Those assessments are downloaded onto their laptops. They disconnect, they go out to the consumer's home. They actually conduct the assessment. They enter all the clinical data, all the demographic information about this consumer. The system then calculates and shows to the assessor what are the potential options available based on the medical eligibility and the consumer's financial circumstances. It still requires the nurse to use her clinical judgment and to know based on that information, what is going to be the best match for the consumer.
Cindy DiBiasi: Was it difficult to implement any parts of this approach?
Molly Baldwin: It was difficult to get all the players to come together and agree that yes, we will collaborate and cooperate, and in the design of the system, all of the players actually participated. So, even frontline assessors participated in the design of the system so they could get a sense of what it was like. We did have concerns of how consumers would react with assessors sitting in their homes using a laptop computer, but that turned out to not be an issue at all. Probably one of our greatest challenges was getting RN's up and ready to use laptop computers because they typically are not computer literate. So the transition from a paper to a technical application was kind of difficult. They wouldn't give it up for anything now that they have been on it since 1998.
Cindy DiBiasi: Well, I guess that answers my next question, which is how has it been working?
Molly Baldwin: It has been working great. We do about 22,000 assessments a year. A typical assessor does about 10-12 assessments a week.
Cindy DiBiasi: What have the costs been of this initiative and how does it compare to any savings that you may have realized by being better able to meet the needs of the frail elderly in the community rather than in the nursing home?
Molly Baldwin: The cost of actually developing this system was about two million dollars. The ongoing cost on an annual basis is to replace the laptops, because they are used by the assessors in all different kinds of settings. The cost benefit has been great. Later on I will talk about what savings we have experienced by transitioning people from institutional-based care to community-based care.
Some of the benefits that we have by entering all this data into this database is we are now able to compare data across settings, be it residential care, be it nursing home, or be it community-based care. It also demonstrates that we truly are serving people with similar characteristics, both in the community and in institutions. So it sort of alleviates the argument that you have to live in an institution and have 24-hour-a-day care when you age.
It also has allowed us to develop an acuity-based reimbursement system that the legislature mandated. We are in the process; we are on the cutting edge of developing quality indicators for home care programs. We are doing that by being able to analyze all the data we have from these assessments.
Cindy DiBiasi: Are there any further enhancements or applications planned?
Molly Baldwin: Yes, we continue to hope that with the development of these quality indicators, we are actually going to provide the assessor different mixes and matches of data items. That is going to send up red flags for her, for her to do additional education of the consumer.
Cindy DiBiasi: Molly, thank you. We are going to come back to you with lots of questions. I'd like to move on now to Terry Williams.
All of you on this call are probably familiar in one way or another with the concept of Smart Cards, those small machine-readable cards that you can carry with you that contain information useful in making everyday transactions. In fact, any of you who have credit cards or ATM bankcards are already using a form of Smart Cards.
Well, the Western Governor's Association in several States is involved in a series of pilot projects to test the use of Smart Cards that allow people enrolled in public healthcare programs to have important health-related information with them at all times and to make that information available when they see a healthcare provider.
Terry Williams is from the State of Wyoming and he is the Field Demonstration Manager for the Western Governor's Association's Health Passport Pilot Project. He is also the Electronic Benefit Transfer Manager with the Wyoming Department of Health and Family Services.
Terry, thanks for joining us from Wyoming.
Terry Williams: Thanks, Cindy. It's wonderful to be here with you.
Cindy DiBiasi: Good. Let me ask you first of all, what issues, what problems are these pilots specifically trying to address?
Terry Williams: Well, Cindy, the issue really is communication of relevant and timely health information between providers. Most programs basically are kind of smokestacks in terms of they do a wonderful job in terms of delivery of services, but they really are extremely limited in terms of the ability and the communication process between the various programs and providers.
Health Passport is an electronic tool. It is a Smart Card to help citizens and parents manage their child's medical care. It supports the concept of family-centered, community-based, and coordinated care and acknowledges that the informed parent is the key to optimizing preventative health services.
Health Passport is a portable medical record that details a child's acute, chronic, and preventative care. According to Bill Gates, using a Smart Card is like putting a computer into your wallet. The Health Passport also helps the provider, the public and the private provider, in that the administrative and the demographic and the clinical and the nutrition information, and the most recent data. That is the test, that is, that the common or shared information across programs, across the majority of the Maternal and Child Health programs, is available on the card as the client arrives at the clinic.
Cindy DiBiasi: What is the solution that you are testing and where are these pilots are being conducted?
Terry Williams: Cindy, the pilots are, first of all, in terms of the solution, we are looking at a Smart Card. This is a picture of the Smart Card; it is our Health Passport card that we are using. It is the one card that is used by the parent for each child. It has an 8K microprocessor. In other words, it is able to manage about eight pages of typed medical information. The card contains up to 500 data elements and these data elements are important in that this is the shared information across the various health programs such as immunization, the Head Start program, maternal and child health, the WIC [Women, Infants, and Children] program. If the card is lost or stolen, we have the ability to use the Internet to back up and restore the card. There is also a magnetic stripe on the card, Cindy. This is used for Medicaid access.
Cindy DiBiasi: Let's talk a little bit about where these pilots are being conducted.
Terry Williams: Sure. The demonstrations across the three States are taking place in three western States. In Cheyenne, Wyoming, in Reno, Nevada, and in Bismarck, North Dakota. The Western Governor's Association approached this in terms of they were extremely interested in the management of information technology as being the key to bringing efficiency to State-delivered health programs and to the citizens who are participating in those programs.
As you can see, it is a three-State initiative in three different communities. The pilot involves the maternal and child health programs in those communities. Basically a 20,000 caseload of mothers and children. There are 17 different programs that are participating in the three particular States. In addition, we have electronic benefit transfer on the cards, both in Wyoming and in Nevada. This is significant in that the WIC food prescription is on the card and also when the client uses the card at the store, there is also an addition to the transaction. There is a printout of the appointments that are pending for the child. In addition, we have private providers participating here in Cheyenne at the Cheyenne Children's Clinic and up in Bismarck at Med Center One.
Cindy DiBiasi: Terry, just to put this in perspective, it looks like a very comprehensive program. We are talking about 20,000 people in three States with 17 local partner organizations. As far as you know, is this one of or if not the largest or most comprehensive pilot out there?
Terry Williams: Yes, I think it is, Cindy. From the perspective of, you can do almost anything in one individual State, but when you actually are looking across three communities in three different States and planning to test the value and the integrity of the system, then I think it is really pretty significant.
Cindy DiBiasi: Great. Tell me a little bit more about these pilots and how they operate.
Terry Williams: Well, basically the issue is using the technology in order to facilitate as transparently as possible the delivery of services. The system requires that both the client and the provider use the card, putting it into the reader so that there is an access to the service. Basically, the client puts the card into the reader and then the provider has their own card that they put into the reader and then they have an access to facilitate the personal to addressing the privacy in terms of each person working within their own particular health domain. The clerk is able to look at administrative and demographic information and read and write to the card. The nurse and the nutritionist are able to look at the lab tests and read and write in terms of any new relevant data. The physician, of course, looks at the diagnosis and is able to read all of the information that is on the card. Just slipping through the next couple of slides here. We have the Legacy Integration is probably the feature that is of most value to the providers in that what it does is it allows the provider to actually be writing in terms of their own software, in terms of the Legacy system, and at the same time they are transparently writing to the card. So that as the worker enters data into their Legacy system, the application at the same time is writing to the Health Passport card in terms of updating it. Or taking information that came from the other providers and putting it into their system. Therefore the staff doesn't have to learn a new system.
People would be perhaps interested in terms of what is specifically on the card. The column on the left side basically shows the information of all of the various programs that are participating in the application. The WIC and the electronic benefit transfer, the nutrition program status information, each child's immunization data, the Medicaid database that is coming from the various child health screenings, the Head Start application in terms of what the Head Start Health Coordinator needs, the maternal and child public health nurse, what they need from the perspective of managing child health care and then the private providers who in many instances are the primary care provider in delivering the service to the mothers and children at Cheyenne Children's Clinic and at Med Center One up in Bismarck.
On the right hand side of the...
Cindy DiBiasi: Terry, I hate to interrupt you, but I am just being notified that we are getting a lot of feedback. If you could use your phone handset rather than a speakerphone or computer, that would be better in terms of our feedback problem.
Terry Williams: Thank you, Cindy, I will do that. I hope this is better. What we have basically on the right hand side of this picture is all of the family programs by status that the family may need to be referred to or they may be participating in at this point in time. So on the left, you have got a complete picture of basically all of the programs in the three States that the client is participating in and on the right hand side you have the various programs that you may be making referrals to.
Further, in terms of what is on the card... Looking at this next card, we have a picture of the medical results that are available to the practitioner that is on the card. Basically timely and relevant, the most current information relative to heights and weights, hematocrits, hemoglobins, immunizations, the pregnancy status and when the mother is due, gravita, parity, CDC [Centers for Disease Control and Prevention] breastfeeding information, and then, of course, the complete examination in terms of the various body systems in terms of hearts, lungs, hearing, vision. Basically the whole cadre of information that is needed in terms of doing the health assessment of the child and the information that is available from the other participants in the program.
Cindy DiBiasi: So it is very comprehensive.
Terry Williams: Yes it is.
Cindy DiBiasi: Now I understand you recently had an independent evaluation done on these pilots. What did you find?
Terry Williams: Cindy, the evaluation was done by the Urban Institute in Phoenix Maximus. The most significant thing was that mostly the providers and the clients really liked the system from the perspective of it brought efficiency to them. The parents felt that it was a way of enabling them and helping them be really at the center of managed care for their family. The issue of security and privacy wasn't nearly the issue that we thought that it might be. People are very comfortable in terms of using the card and sharing the secure information that was available from the other participating providers. We did have probably maybe two or three clients per thousand of the 20,000 participants who, because it was voluntary, they just said thanks, but no thanks. From the perspective of being able to share secure, timely and relevant information across the providers, the parents felt very comfortable, and the staff, because of the fact that everybody was operating within their own scope of practice, they all felt that the security was more than adequate in terms of being able to access and share information.
Cindy DiBiasi: Well, if the questions that we are getting are any indication in the interest in Smart Cards, I can see that is something really interesting and timely here. We are going to come back to you because we do have a lot of questions from the audience on Smart Cards.
Terry Williams: OK. We will be right with you.
Cindy DiBiasi: OK. Before we go back to Terry, I want to move on to Sandra Shewry. She is the head of the agency responsible for the State of California's State Child Health Insurance Program or SCHIP. It is a new initiative established by Congress several years ago to extend health care coverage to uninsured children previously not eligible for Medicaid.
In many States that had problems reaching and enrolling eligible children in the program, California is now moving to statewide implementation of a new Web-based enrollment program called Health-e-App, which has been pilot tested in one county. Sandra, welcome.
Sandra Shewry: Thank you, Cindy.
Cindy DiBiasi: Many of us are familiar with the new SCHIP program which provides healthcare coverage to uninsured lower income children previously not eligible, but we also know that many States have had problems in reaching and actually enrolling eligible children in the program. Did California encounter these same problems?
Sandra Shewry: Well, you have correctly stated it. The challenge and the vision for us in all of the States is to both identify and then enroll all the children that are eligible for both Medicaid and SCHIP. In California, our SCHIP program has been operational for three years. We have about 450,000 children enrolled. When we talk to families who aren't enrolled but that we know are eligible, what we learn is that the application process continues to be a challenge. So Health-e-App is one strategy that California is using to try to reduce enrollment barriers.
Cindy DiBiasi: And how are you trying to use informatics technology to address this problem?
Sandra Shewry: Well, our goal with this project is to increase the enrollment of children. Health-e-App does that by improving and simplifying the application process. I am going to show you a slide that illustrates how data flows for applicants in our State. In our State we use trained community workers for outreach. We call them Certified Application Assistants [CAAs]; you see them there on the left hand side of the slide. In California, we have over 20,000 people trained. They all attend a one-day training session and about 7,000 of them are active at any one time helping families.
What happens is the applications are mailed to a single point of entry. That is a concept that a lot of States are using where all applications for Medicaid or SCHIP go into one point. With that application comes quite a bit of paper. You need income documentation, a birth certificate, immigration documents. Those all go into a single point of entry. They take four days to process it, figure out if the child is eligible for SCHIP or Medicaid. If it is eligible for SCHIP, they go up to that box in the upper right hand part of the slide. If they are eligible for Medicaid, the application is transferred to one of 58 California counties. Our single point of entry uses automated business logic to screen the applications. So that part of our system is entirely automated. We have got paper flowing in from CAAs and applicants. That single point of entry today takes four days average processing time.
There is an automated link between the single point of entry and the SCHIP program, but again, it takes seven days for the processing. So you have got 11 days for families to find out if their children are eligible. This doesn't feel to us like state-of-the-art technology. We can do better. For our Medicaid counties, the applications come into our single point of entry and then they go out to 58 different counties. Our State law says that counties have up to 60 days to determine eligibility. So those parallel lines on this diagram are the three "pipes", if you will, that we are trying to build so that Health-e-App can become a reality. The first pipe is built, and that is the one going to the upper right, between the single point of entry and our SCHIP program. Health-e-App, when we go live this year, will build the applicant to the single point of entry pipe, and then we are going to be rolling out over the next year or so, the 58, if you will, pipes to our 58 California counties.
So, what's the value added here is that there won't be any paper. All those documents I talked about, paycheck stubs, birth certificates. If those are faxed using Health-e-App into our single point of entry, they stay as an image file, they never need to go to paper; the automated system can evaluate the income eligibility of all the documents, and it can be transmitted instantly.
So, in its full implementation, and that is the exciting part about Health-e-App, is that when we are done, we won't need to ever go to paper or put things in the mail.
Cindy DiBiasi: It will be an entirely paperless process.
Sandra Shewry: Exactly.
Cindy DiBiasi: We have heard reference to the "Digital Divide" of the problem that many low-income families don't have access to the Internet and therefore cannot realize its benefits. Is this a concern for you?
Sandra Shewry: It is a concern and the way we think about responding to that concern is that our goal is to basically bring customer service for government programs to the public using the best available technology. As I mentioned earlier, we do extensive outreach for our SCHIP program using community people and county social service offices. Many of them have Web access on their desktops. Now when Health-e-App is fully implemented, our vision is that many of our community workers will have laptops and wireless modems and they will be able to go right into people's homes and work sites or go out to community events. We are developing and implementing Health-e-App with a partner that is shown at the top of the slide, California HealthCare Foundation. They and we are approaching manufacturers to talk about basically creating partnerships where we are able to provide maybe some of the technology that is needed to community members.
Part of using Health-e-App is going to take some training. We think the community partners that we are working with today are going to be excited about it. We are going to have a Web-based training module which is basically going to satisfy two needs: one, we are going to be sure people can use the technology because the training will be right on the Web-based system and number two, we will know they have passed the training and can use the system. Because we don't want to roll out a new technology to the public and have it become more of a frustration than a paper process would be. So that is one of the key components of this, is really getting a Web-based training program in place.
Cindy DiBiasi: Sandra, we do want to get to questions, but could you quickly show us how the Health-e-App Web site works?
Sandra Shewry: Sure. What I would like to do is go through what are some screen shots of the Health-e-App and the resolution on these isn't perfect so we had to import it a couple of different times. Health-e-App is basically, it will be accessed by our community partners and they will have, before they are allowed to use it, as I said, they will have to pass training. So they will have a username and a password. One of the real positives of the system is that it does error checking. This screen shows what Health-e-App looks like. In this case, someone tried to enter a birth date that was less than today's date. We find that many families, if we ask them, "What is your child's birth date?" They will say, well, July 26, 2001, because that is how we are used to writing dates on all our checks and so we do that. Health-e-App stops you from doing that, which means we don't have to call the family and find out what is wrong. Another feature of Health-e-App is it brings our provider directory in our SCHIP program. Families pick a provider, and this screen shows you this family wants a female doctor. They don't have a preference in terms of specialty regarding it being a pediatrician or some other specialty. They are willing to travel ten miles. The system will then give them a list of all the providers that meet that criteria. Indeed, we even have a feature linking to a mapping program so they can see how to find that provider's office from their home.
Now one of the things that families really like about Health-e-App is that it happens in real time. What this screen shows is you have successfully completed the application and your application is now being worked on and we are going to give you an actual eligibility determination. Families value this very much. They want to know, am I even in the ballpark of being eligible for a government program? Should I be waiting? Should I be looking for other sources of care?
Another feature that families really like is what we call the application summary. The application summary basically prints out for the family all the information they have given us. The community worker can keep this on file and that way if the application is determined to be ineligible, we can see if something was wrong, if something happened with the system. While it seems pretty mundane, it has really been very popular with both families and community workers.
To summarize, what is Health-e-App? It is a preliminary eligibility determination. It gives instant error checking, which means over time, our system is going to be cheaper. It lets people select their health plans and providers online. It calculates family income, which for any of us who run government programs, know that that is the big stumbling block. How do we count income? What is the family grouping? The Health-e-App goes right into our internal logic and does those calculations. We can use an electronic signature. You don't have to have an actual piece of paper. That application summary for applicants is just a very popular feature and it allows our community workers to track the applications they have assisted.